Ten years ago, 14 million people voluntarily participated in the HIV testing and counselling campaign. Busani Ngcaweni and Yogan Pillay writes that the government should aggregate this total experience as a backdrop to the planned Covid-19 vaccination programme.
We write this as President Cyril Ramaphosa announced on Monday that the government has put in place an ambitious vaccine programme targeting herd immunity of up to 67% (40 million) of the population.
"Our strategy has several parts. The first part of our strategy is to acquire enough vaccine doses to reach herd immunity," the president said, at what has come to be known as the family meeting (when he addresses the nation on the national Covid-19 response).
Giving further details to what had been earlier communicated by the health minister, the president said 1.5 million doses of the Covid-19 vaccine had been secured from the Serum Institute of India for delivery in January and February.
Ramaphosa assured South Africans that beyond this 1.5 million doses for healthcare workers, 20 million doses are being procured for shipment in the first half of 2021. Essential services workers, such as teachers, police, municipal workers and other frontline personnel, will be prioritised for vaccination during this period, alongside the elderly and people with defined comorbidities. The balance of the high risk population groups will be vaccinated as capacity increases.
Access to the vaccine in SA
Much has been written about access to the vaccine by South Africa – that government has been slow to place orders and that its reliance on the Covax facility was an incorrect strategy.
Both Ramaphosa and the health minister have addressed some of these concerns, which arose out of complex negotiations with vaccine manufacturers, the majority of whom are owned in the global north.
However, some of the critique did not underscore that South Africa has a long history of vaccine procurement, distribution and vaccination programmes, which the implementation of the Covid-19 vaccine rollout plan can build on.
According to UNICEF, childhood vaccinations are the best buy in public health.
It saves an estimated 2-3 million lives every year globally. Every dollar spent immunising children results in an estimated $44 million in economic and social benefits in low- and middle-income countries.
South Africa's expanded programme on immunisation (EPI) provides vaccines to prevent 11 different illnesses, which are given at different times in a child's early life.
- At birth - polio and BCG (to prevent tuberculosis);
- At 6 weeks - second dose of polio, Rotavirus vaccine, Diphtheria, tetanus and acellular pertussis vaccine and inactivated polio vaccine, Haemophilus influenzae type b vaccine, HepB (DTAP-IPV-Hib-HepB), and Pneumococcal conjugate vaccine (PCV);
- At 10 weeks – second dose of DTaP-IPV-Hib-HepB;
- At 14 weeks of age – second dose of Rotavirus vaccine, third dose of DTaP-IPV-Hib-HepB and second dose of Pneumococcal conjugate vaccine;
- At 6 months of age – the first dose of measles vaccine;
- At 9 months – third dose of PCV;
- At 12 months – the second dose of measles vaccine;
- At 18 months - the fourth dose of DTaP-IPV-Hib-HepB;
- At 6 years of age - Tetanus and diphtheria vaccine (Td);
- At 9-10 years - two doses of the Human papillomavirus (HPV) vaccine (6 months apart); and
- At 12 years of age - the second dose of Td.
As is evident from this schedule, the frequency and timing of different vaccinations are complex and may be confusing.
The Road to Health Booklet given to all moms after delivery contains all of this information and space for health workers at the clinic to record each vaccination, so that parents have a record of each vaccine and the subsequent one.
Getting vaccines to each clinic and hospital is a major task for the public healthcare system and requires a robust procurement, distribution and cold chain system, which also tracks the need for vaccines as well as stock levels to ensure that there are no stock-outs (in fact, the private healthcare system goes through the same rigorous process).
On the demand side, the Department of Health needs to know how many children are born in each district, so that the correct volume of vaccines can be procured, and staff at clinics need to know the number of children in each of the age cohorts to ensure that regardless of which age the child is, which vaccines should be available according to the EPI schedule.
Occasional glitches notwithstanding, millions of doses of vaccines are procured and distributed by the Department of Health for the public health sector annually.
To illustrate: 6.7 million doses of measles vaccine and 6.1 million doses of polio vaccine were procured and distributed in 2020. This is an essential healthcare service that the government provides to its citizens, an investment in the future, as UNICEF puts it.
Impact of SA's vaccination programme
The private health sector also contributes to the provision of childhood vaccinations through private hospitals and private pharmacies. This public-private partnership extends access whilst reducing queues in public clinics.
It should be noted, too, that South Africa does vaccinate adults for HPV and Yellow Fever, among others.
What is the impact of the country's vaccine programme?
South Africa has been certified as polio free by the World Health Organisation. There are currently only two countries globally that have wild polio virus circulating in their communities – Afghanistan and Pakistan. It is very unlikely to find a 20-year old with polio in South Africa as the polio vaccine was ramped up by the democratic government.
The number of laboratory confirmed measles cases has also declined to 0.4 per million, which is lower than the WHO's pre-elimination target of less than one million.
To further reduce deaths in children from diarrhoea and pneumonia, the government introduced two new vaccines in 2009: rotavirus vaccine and pneumococcus vaccine. These new additions to the immunisation programme have made a significant impact, according to surveillance data: a 60% reduction in children hospitalised due to diarrhoea caused by rotavirus and a 40% reduction in pneumonia cases.
Lessons from SA's AIDS response
Most recently, in 2014, the Department of Health introduced the human papilloma virus (HPV) vaccination for nine-year-olds in Grade 4. By the end of 2020, more than two million school children had been vaccinated against this virus which causes cervical cancer.
Annually, more than 5 000 cases of cervical cancer are reported to the National Cancer Registry, with over 3 000 deaths. The goal of the WHO is to eliminate cervical cancer through vaccination, screening and treatment. In fact, many countries that led the way with HPV vaccination are near elimination cervical cancer caused by this virus.
Even as the country gears up to leverage its experience and expertise to effectively rollout the Covid-19 vaccine, it is important to note lessons from the successful national AIDS response.
- First, we should not be complacent and take for granted the importance of non-pharmaceutical prevention measures. We must wear our masks covering the mouth and nose. We must stay away from crowded places and not go to funerals unless it is absolutely unavoidable because of close family ties. We must wash and sanitise our hands. And as we move around to work and to buy essential supplies, we must keep the distance from others. Avoiding contact with our parents and grandparents is the new way of showing love.
- Second, we need to intensify awareness messages and the behaviour change campaign in order to reach out to key population groups, like young people who go to super-spreader events, the elderly, school children and all essential services workers. It should be emphasised that removing the mask after a few minutes of encounter with our friends and colleagues is the same as removing a condom after few months of intimate encounters - keep it safe as, like with HIV, you do not know the person's status unless you have both tested.
- Leveraging stakeholder support and building international solidarity. This was perhaps the game changer in the national AIDS response as support and resources were mobilised to support community-based responses, treatment, care and support as well as above the line campaigns. Reports of positive engagements between the government, Covax partners, the African Union and key BRICS partners, particularly Russia and China are encouraging. International solidarity is key to the global fight against this pandemic and South Africa is not just a recipient of supplies from China, Germany and the United States, we have also shared our limited resources with countries like Cuba.
We are aware of the conspiracy theories around the vaccines, which are compounded by the political economy of intellectual property regimes and terms of trade that favours countries of the global north.
We are, however, encouraged that public confidence is rising as the leadership continues to communicate a national vaccination strategy which, as we have demonstrated, should build on the solid foundation of the national vaccination programme which has reached millions of South Africans.
About a decade ago, over 14 million people voluntarily participated in the HIV testing and counselling campaign. Millions went on to be initiated on anti-retroviral therapy.
The government should aggregate this total experience as a backdrop to the planned Covid-19 vaccination programme.
Again, as ably demonstrated through the national AIDS response, all social partners have a role to play and should be effectively engaged. For example, SA would not have successfully implemented the medical male circumcision programme had it not been for the support of traditional authorities in provinces like KwaZulu-Natal.
- Busani Ngcaweni is Principal of the National School of Government. Yogan Pillay is former Deputy Director-General for Strategic Health Programmes at the National Department of Health. They spent over 14 years supporting the national AIDS response through the SA National AIDS Council.
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